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Kinesthetic stimulation for treating apnea in preterm infants

Rocking therapy and physical stimulation have been advocated to assist preterm infants to breathe regularly and some have been designed to mimic in utero movements. A pause in breathing (apnea) is common in very preterm infants but it can lead to a lack of oxygen in the blood, so that the infant needs resuscitation and assisted ventilation. Pauses in breathing could also affect brain development and proper functioning of other organs. Physical stimulation is recognised as a means to wake up preterm infants who then start breathing on their own. Three controlled studies have used different gentle rocking motions (irregularly oscillating water beds, regularly rocking bed trays or a vertical pulsating stimulus) to reduce the occurrence of apnea in a total of 49 babies. However, there was no clinically useful reduction of periods of apnea, although only a small number of infants were studied. Shorter breathing pauses were reported to be reduced by one study but it is not thought to be clinically important. No harm has reported to be done to the preterm infants with these interventions.

Authors' conclusions:

There is insufficient evidence to recommend kinesthetic stimulation as treatment for clinically significant apnea of prematurity. Previous reviews have suggested that kinesthetic stimulation is not effective at preventing apnea of prematurity (Henderson-Smart 2005) and is not as effective as theophylline at treating clinically significant apnea of prematurity (Osborn 2005).

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Background:

Recurrent apnea is common in preterm infants particularly at very early gestational ages. These episodes of loss of effective breathing can lead to hypoxemia and bradycardia, which may be severe enough to require resuscitation including use of positive pressure ventilation or other treatments. Physical stimulation is often used to restart breathing and it is possible that repeated kinesthetic stimulation might be used to treat infants with apnea and prevent its consequences.

Objectives:

To determine the effect of kinesthetic stimulation on apnea and bradycardia, the use of mechanical ventilation or continuous positive airways pressure, and neurodevelopmental disability in preterm infants with apnea.

Search strategy:

The standard search strategy of the Cochrane Neonatal Review Group was used. An updated search was performed in October 2009 of MEDLINE and PREMEDLINE, EMBASE, CINAHL and CENTRAL (The Cochrane Library).

Selection criteria:

All trials using random or quasi-random patient allocation that compared kinesthetic stimulation to placebo or no treatment in preterm infants with apnea of prematurity.

Data collection and analysis:

Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used. As all three included trials were crossover trials, the data were extracted from all exposure periods and combined where appropriate.

Main results:

Three crossover studies (Korner 1978; Tuck 1982; Jirapaet 1993) were identified that compared a form of kinesthetic stimulation to control for the treatment of apnea of prematurity. No study reported a clinically important reduction (> 50%) in apnea. Using a lower threshold (> 25%), Korner 1978 reported less apnea and bradycardia in infants while on an oscillating water bed. Tuck 1982 demonstrated a reduction in frequency of apneas (> 12 seconds) associated with bradycardia (< 100 bpm), apneas associated with hypoxia (TcP02 < 50 mmHg), and apneas requiring stimulation in infants on a rocking bed. Individual patient data were not available from the author to determine if there was an important reduction in clinical apnea. No outcome could be extracted from the study using a 'vertical pulsating stimulus' by Jirapaet 1993 that was consistent with the definition of clinically important apnea. Jirapaet 1993 reported no infants required resuscitation or ventilation. Adverse events such as death, intraventricular hemorrhage and neurodevelopmental disability were not reported.